What to Know About Accepting Insurance

So you decided to start taking insurance for various reasons.  Maybe you want mental health services to be more accessible.  Maybe you’re looking to build your caseload with insurance clients.  Or you like the idea of being able to market yourself as an in-network provider.  Whatever your reasons are, it’s important that you understand how the insurance game works so you’re prepared, can answer client inquiries, and protect yourself from losing/paying back money.

We’ll first start with some basic insurance terms:

Copay- A copay, or a copayment is what the client owes as their portion for a service.  It’s important to understand the ramifications of selecting plans with low premiums as they often have a high copay.  You need to think about how often you’re going to use/likely going to use insurance to gauge the best plan.  While a smaller monthly premium sounds nice, you may end up paying more over the year if you have higher copays.

Co-insurance- Co-insurance is an amount of a service that you owe, usually a percentage.  The co-insurance amount often changes once a deductible is met so it’s important to consider this when a client is hit with a high co-insurance amount considering opting out.

What’s the difference?

A copay is usually a fixed amount for a service.  If a counselor does a 45-minute session or a 53-minute session, the amount will usually be the same.  A co-insurance is a percentage so let’s say you provide a 45-minute session and the contractice rate is $100.  If they have an 80% co-insurance, they’ll owe $80.  If the same client has a 60-minute session(which is a different and higher-priced service) and the contracted rate is $140, they’ll pay $112.

Deductible- A deductible is an amount you need to pay before certain benefits kick in.  For example, you may have a deductible of $5,000 and owe 100% of costs before a 20% co-insurance kicks in.  This means that if you are seeing a counselor and the contracted rate is $150, you’ll need to pay for $5,000 worth of covered services before you’ll be charged $30/session(20% of the $150 rate.)

It’s important to know these terms so you can explain it to potential clients.  If you can’t answer their questions, they’ll often find someone who can.

FAQs

Q. I did a verification for a client and it’s says they owe 100% of the contracted rate but they tell me that they should only owe $10 per session, what do I tell them?

A. Someone’s wrong.  It’s unfortunately common that an estimate comes back incorrect or a client is mistaken.  If this happens, request supporting documentation and if you work with a company like Headway or Alma, you can request a manual verification.  It may also mean that certain services aren’t covered by someone’s plan.  For example, they may not have telehealth covered and aren’t aware.

Q. My client said that they used to pay $X/session but now they’re being quoted something higher, what do I tell them?

A. There may be a few reasons for this:

-One reason is they saw a provider that used a different biller that contracted a lower rate than your biller.  While increased rates for the provider sound nice, it may mean that clients will pay more out of pocket.

-Another common reason is that their deductible reset.  If their deductible reset then they may have changed from a lower co-insurance to a higher one.

-A change was made in their plan and they weren’t aware or didn’t do their homework.  It’s common for people who don’t fully understand insurance to take plans that aren’t the best.  Lower monthly premiums sound nice but if it means a higher deductible/co-insurance, they may be paying way more if they need to use their insurance for an unexpected accident or illness.

-An error was made during the verification process.  If the client is confident that the estimate is inaccurate, you may need to request that the verification be double-checked and be prepared to supply supporting documents

Q. My private pay rate is lower than the amount they’ll pay with insurance, what are their options?

A.  A client usually has the option to opt out of insurance which means that they don’t want to utilize those benefits but they need to understand what this means.  A client can opt-out but can’t be coerced by the provider to do so.  If someone asks if they can just pay cash they’ll need to know the following:

-Cash payments will not go toward their deductible.  If they’ll likely meet their deductible, they might pay more in the long run by paying a cash rate if they have other medical bills that will satisfy the deductible.

-Opting out of benefits means they opt out of all benefits.  If they pay your cash rate, they cannot submit for out-of-network benefits.

-They can later request to use benefits for various reasons(i.e a deductible was met and the cost is now lower).

Q. I use a company like Headway/Alma for insurance.  Someone contacted me through my website about counseling and I found out that they have insurance I’m in-network with, do I have to see them using insurance?

A. This one isn’t as cut and dry and you’ll find a lot of differing opinions on this one.  My take is this, even if you don’t have to tell them, how would you feel if a provider willingly withheld information for their benefit?  A lot of providers may say, “Since my biller submits claims using a different Tax ID, I can bill privately and not have to worry that the OON claim will get rejected.”  Insurance companies are becoming savvy with this practice and finding ways to reject claims stating that the provider did have the ability to bill insurance.  If you’re willing to take that risk, you might find yourself having to deal with a client complaint.  Clients are also becoming savvy in finding out if you’re INN somewhere.  Since companies like Alma and Headway list you in their directory, you may have some explaining to do if they find your profile and ask why you didn’t tell them they had insurance as an option.  There are some workarounds like having a separate physical office that houses a business that is cash only, but if they’re ok with coming to a different office or being seen virtually, you may find yourself in hot water if you deny their preference to use insurance.

Q. I see that some CPT codes pay less and I don’t like that, can I refuse to accept them?

A. You can’t pick and choose which codes you’ll accept and which ones you won’t(unless there’s a service you don’t provide for example, I don’t do couples therapy at all so I don’t see them even if they want to pay cash).  Couples therapy comes into play here as insurance usually pays less for the CPT code 90847 which is often used when a couple wants to be seen together.  You can say “I don’t see couples” but you can’t flat-out say “I don’t bill 90847, you’ll have to pay my cash rate.”  There are some things to consider though.  If they are coming to you for something as a couple that doesn’t apply to the 90847 criteria, you may be able to see them for your cash couples rate.  Barbara Griswold goes over that criteria well in her article. https://theinsurancemaze.com/articles/couples/.  While this is admittingly frustrating that insurance pays less for this, this is part of the contract you signed when you decided to panel with insurance.

Q. I’m paneled with X and Y insurance but X pays less than Y insurance, can I stay paneled with X insurance but refuse to see new clients with X insurance but accept clients with Y insurance?

A. You’re looking for a complaint if you do this.  You’ll either have to lie by saying “I’m sorry, I’m not accepting new clients” or give them some other reason to avoid the lower rates.  You can choose to not advertise that you’re INN with X insurance, but the best practice is to be honest with them and let them know that you do have openings and are INN with their insurance.  You can depanel with that insurance, let them know the timeline, and let them decide if they want to start and either pay cash or find a new provider when the contract is terminated.  I’ve also heard providers say “Well I only see insurance clients on Mondays and my Mondays are full so I require they pay cash if they want to see me.”  This is also asking for a complaint.  There are some workarounds for this but the ones I’ve found all seem pretty shady, even if they are viable, I wouldn’t see a provider who is looking for loopholes for their benefit.

Q. I’m terrified of clawbacks and hear people complain all the time about these, what can I do?

A. First, keep in mind that if 100 claims are submitted and go through smoothly, nobody is rushing to a forum to tell people.  If 100 claims are submitted and get rejected, you better believe people will want to complain about it.  Complaints are often the majority of the posts but the minority of the actual claims being processed.  My best suggestion is to do your homework before you even start taking insurance.  There are a lot of really good documentation trainings out there so make sure you take some to avoid costly mistakes later.

Q. They didn’t teach us this stuff in grad school, what else do I need to know about taking insurance?

A. I suggest having good policies to protect yourself.  Some policies I implement are:

-Requiring autopay.  This is common practice and a great way to protect yourself.

-No future session can be scheduled/held until all previous invoices are paid.

-CC/separate CC in EHR.  Clients have been known to remove cards to avoid being charged, have cards get declined, or have cards expire.  A different card in your EHR can allow you to charge for services as outlined in your policies.  Make sure that this isn’t violating a contract you may have signed with a biller.

-Have it in your policies that clients are responsible for future costs if an estimate is later found to be incorrect.

-Verbally go over the main parts of your policies as clients usually won’t read everything.  While a signed policy form is good protection if they file a grievance, it’s always easier to do your due diligence and make sure they understand what they are signing.

I hope this article covered most of the questions that people ask when agreeing to panel with insurance companies.  One last suggestion I’ll make to get answers is this:

-Google it.  I often see questions being asked in forums that a quick Google search will answer.  A lot of the questions have been asked before and someone has likely written an article or has a resource to answer them.

-Search past posts.  Before you post a question on a forum, utilize the search tool and see if someone has already asked your question.  A lot of people leave forums due to the redundancy of questions being asked which means they take their knowledge and expertise with them.  It’s often faster to get an answer too if it’s already been answered and you don’t have to wait for others to respond to your post.

Anything I missed?  Anything in this article that needs correcting or clarifying?  Feel free to contact me and I hope you found this useful.